Effects of Rural Sanitation on Infant Mortality and Human Capital: Evidence from India's Total Sanitation Campaign
Dean Spears
Abstract: Open defecation without a toilet or latrine is among the leading global threats to health, especially in India. Although it is well-known that modern sewage infrastructure improves health, it is unknown whether a sanitation program feasible for a low capacity, poor country government could be effective. This paper contributes the first causally identied estimates of effects of rural sanitation on health and human capital accumulation. The Indian government's Total Sanitation Campaign reports building one household pit latrine per ten rural persons from 2001 to 2011. The program offered local governments a large ex post monetary incentive to eliminate open defecation. I use several complementary identification strategies to estimate the program's effect on children's health. First, I exploit variation in program timing, comparing children born in different years. Second, I study a long difference-in-differences in aggregate mortality. Third, I exploit a discontinuity designed into the monetary incentive. Unlike many impact evaluations, this paper studies a full-scale program implemented by a large government bureaucracy with low administrative capacity. At the mean program intensity, infant mortality decreased by 4 per 1,000 and children's height increased by 0.2 standard deviations (similar to the cross-sectional difference associated with doubling household consumption per capita). These results suggest that, even in the context of governance constraints, incentivizing local leaders to promote technology adoption can be an effective strategy
How much international variation in child height can sanitation explain?
Dean Spears
Physical height is an important economic variable reflecting health and human capital. Puzzlingly, however, differences in average height across developing countries are not well explained by differences in wealth. In particular, children in India are shorter, on average, than children in Africa who are poorer, on average, a paradox called “the Asian enigma” which has received much attention from economists. This paper provides the first documentation of a quantitatively important gradient between child height and sanitation that can statistically explain a large fraction of international height differences. This association between sanitation and human capital is robustly stable, even after accounting for other heterogeneity, such as in GDP. The author applies three complementary empirical strategies to identify the association between sanitation and child height: country-level regressions across 140 country- years in 65 developing countries; within-country analysis of differences over time within Indian districts; and econometric decomposition of the India-Africa height differences in child-level data. Open defecation, which is exceptionally widespread in India, can account for much or all of the excess stunting in India.

Perhaps the most disturbing thing of all is the simple summary statistic that there are many regions where >50% of households do not have toilets.

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